Introduction
Tuberculosis (TB), though preventable and curable, remains a major global health threat, regaining its position as the foremost infectious killer in 2023. 1 In that year, an estimated 10.8 million people developed TB worldwide, with 1.25 million deaths, including 161,000 people with human immunodeficiency virus (HIV). 1 South-East Asia and Africa continue to carry the highest TB-burden, with Namibia among the top 30 high-burden countries globally. 1
Across Africa, weak health systems, limited healthcare access, and high HIV prevalence undermine TB control efforts. Reference Anaemene2 Namibia faces similar challenges, where the HIV-TB co-epidemic disproportionately affects marginalized and poor communities. Reference Shilongo, Tettey and Munford3 Nonetheless, progress has been made, with a reduced case notification rate of 468 per 100,000 people in 2023. 4
To curb TB transmission in healthcare settings, the World Health Organization recommends TB infection prevention and control (IPC) measures, including administrative controls, environmental measures, and personal protective equipment (PPE). 5 Although Namibia’s national IPC policies support these measures, inconsistent implementation and knowledge gaps among healthcare workers (HCWs) persist. Reference Masuku, Olorunju, Shirley Mooa, van der Walt and Doriccah Peu6,Reference Mulokoshi7
Although early studies revealed inadequate knowledge about TB IPC among HCWs, Reference Buregyeya, Kasasa and Mitchell8,Reference Shaanika9 more recent evidence suggests an improvement in knowledge, alongside gaps between knowledge and actual practice. Reference Shihora, Damor, Parmar, Pankaj and Murugan10 Trained HCWs and those with higher qualifications or formal TB IPC education generally demonstrate greater knowledge and improved TB IPC practices. Reference Akwaowo, Umoh and Motilewa11
Barriers to effective TB IPC include fragmented HIV/TB services, weak policies, limited funding and infrastructure, weak leadership, inadequate knowledge and training, low PPE use, stigma, poor risk perception, unsupportive work culture, and competing workloads. Reference Tan, Kallon, Colvin and Grant12,Reference Houghton, Meskell and Delaney13 Facilitators include targeted training, supportive leadership, good communication, sufficient resources, and a strong safety culture. Reference Tan, Kallon, Colvin and Grant12,Reference Houghton, Meskell and Delaney13 Evidence also suggests poor TB IPC implementation in high-burden settings often stems from the absence of policies, poor policy enforcement, or poorly informed HCWs, increasing their exposure to TB. Reference Nazneen, Tarannum and Chowdhury14,Reference Grobler, Mehtar and Dheda15
In the //Karas region, a high TB-burden area in Namibia, no comprehensive assessment of HCWs’ knowledge, attitudes, and practices (KAP), barriers, and facilitators of TB IPC implementation and adherence has been conducted. Additionally, the practical effectiveness of IPC policies and potential policy gaps have not been assessed.
This study aimed to evaluate the TB IPC challenges at public health facilities in the //Karas region, Namibia. The specific objectives were to (1) evaluate HCWs’ providing TB services KAP regarding TB IPC, (2) assess the barriers and facilitators to the implementation and adherence to TB IPC procedures, and (3) evaluate policies aimed at TB IPC at public health facilities in the //Karas region.
Methods
Study design
We conducted a concurrent mixed-methods study in the //Karas region, Namibia. The quantitative phase involved a cross-sectional survey of the TB IPC KAP of HCWs providing TB services at public health facilities, as well as barriers and facilitators to TB IPC adherence (phase 1), while the qualitative phase comprised focus group discussions (FGDs) with TB focal persons from District Coordinating Committees (DCCs) of each district within the region (phase 2).
Study setting
//Karas is Namibia’s largest region in the South, covering 161,514 km2, with a population of 109,893, and 3 districts (Keetmanshoop, Lüderitz, and Karasburg). 16,Reference Kateta17 The health and social work industry employs around 672 people. 18 The region’s public health system comprises district hospitals, clinics, and health centers that refer patients to intermediate and specialist hospitals in the capital, Windhoek. The region has 23 public health facilities under the Ministry of Health and Social Services (MoHSS), but only 15 provide TB services. 19 Each district hospital’s DCC plays a key role in implementing the National TB and Leprosy Programme. The DCC also oversees health management, planning, and coordination within the district, ensuring the implementation of TB IPC measures in the public and private sectors.
Study population and sampling
For the quantitative phase, eligible participants were HCWs (eg, doctors, nurses, environmental health personnel, and other HCWs) involved in TB services at public health facilities in the //Karas region employed for > 6 months. HCWs with < 6 months’ experience at their current facility, those on leave during data collection, and hospital staff involved in administration and management were excluded.
FGD participants were TB focal individuals from DCCs, including Senior Medical Officers, primary healthcare (PHC) supervisors, District TB and Leprosy Coordinators (DTLCs), and Heads of Departments (HoDs) of each district hospital in //Karas region. Private health supervisors, HoDs, and managers or executives of non-governmental organizations were excluded.
Non-probability sampling techniques were employed for both study phases, convenience sampling for the quantitative phase and purposive sampling for the qualitative phase. A sample size of 203 was calculated for the quantitative phase, targeting a 95% confidence level (CI) and a 3% margin of error, with an estimated population size of 250 HCWs. However, 102 responses were obtained, resulting in a 7% margin of error. For the qualitative phase, each FGD comprised 5–8 participants, conducted separately in the 3 districts.
Data collection
An online KAP questionnaire was developed in English using Google Forms (Supplemental File 1). The questionnaire consisted mostly of closed-ended questions and was designed to assess TB IPC-related KAP among HCWs. The questions were informed by the MoHSS TB IPC Guideline 2021, 20 National Guidelines for the Management of Tuberculosis 4th Edition 2019, 21 and some were adapted from a similar study. Reference Shrestha, Bhattarai, Thapa, Basel and Wagle22
Knowledge was operationalized through 10 multiple-choice questions (true, do not know, false) assessing respondents’ understanding of TB transmission, symptoms, IPC measures, and relevant guidelines. Scores were calculated based on the number of correct responses, with higher scores indicating greater knowledge. Attitudes were measured using a 3-point Likert scale (agree, neutral, disagree) with 10 questions gauging respondents’ beliefs, perceptions, and willingness to implement TB IPC measures. Practices were measured using a 3-point Likert scale (always, sometimes, never) with 20 questions evaluating the implementation of IPC (administrative, environmental, and personal protective control) measures in practice. Barriers and facilitators were measured through open-ended questions exploring factors influencing adherence to TB IPC procedures.
The questionnaire was reviewed by 2 TB experts, the Karas Regional TB Leprosy Coordinator and a senior lecturer from the Namibia University of Science and Technology (NUST). The online questionnaire was pilot tested by 10 HCWs providing TB services within the region, who were excluded from the main study. Drawing on the expert input and the pilot test, the survey was revised and refined before data collection.
The questionnaire was emailed to HoDs at public health facilities for distribution through email or digital communication groups. Reminder emails were sent biweekly.
Three FGDs were conducted with DCC members from each district. An FGD guide (Supplemental File 2) was used to evaluate TB IPC policies and identify barriers and facilitators to their implementation. Invitation emails were sent, and written consent was obtained prior. FGDs were moderated by the researcher, audio-recorded, and notes taken by a research assistant. Data collection spanned 8 months (April 17–November 10, 2023).
To ensure credibility, the researcher employed discussion techniques during FGDs, rephrasing and clarifying questions to elicit clear and consistent responses, which increased participant engagement. Transferability was supported through a detailed description of the study context, population, FGD process, and findings, including participant quotations. Dependability was achieved by ensuring error-free transcription accurately reflecting participants’ responses. Confirmability was maintained through reflexivity, with the researcher taking reflexive notes during FGDs to minimize bias. To reduce respondent bias, discussion points were shared in advance, allowing participants to prepare thoughtfully.
Data analysis
Questionnaire data were extracted and cleaned in Excel and imported into IBM SPSS for Windows Version 28 23 for analysis with support from a statistician. Descriptive statistics were used to summarize KAP responses as well as report barriers and facilitators.
KAP responses were scored using the method described by Akande. Reference Akande24 Correct knowledge responses scored 1; incorrect or “don’t know” scored 0. Scores ≥ 60% indicated good knowledge. For attitudes, a score of 1 was assigned for responses suggesting a positive attitude, and 0 for other responses. Respondents were considered to have a positive overall attitude if they scored ≥ 60%. Practice scores assigned 1 to “always” responses; other responses scored 0. “Not in my scope of practice” responses were excluded. Practice scores ≥ 60% were classified as good. Reference Ajayi and Isiyaku25 The internal consistency of the KAP scales was assessed using Cronbach’s Alpha, with values between .7–.95 considered acceptable; however, values below .7 may be secondary to a low number of items or multiple underlying factors. Reference Tavakol and Dennick26
Bivariate analysis using the Pearson χ2 test of Independence (P < .05) was conducted to identify associations between knowledge scores and respondent variables. Barriers and facilitators were grouped thematically and presented in frequency tables.
FGD recordings were transcribed verbatim using Microsoft Transcribe. Thematic analysis was conducted following a 6-phase approach, which includes data familiarization, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report. Reference Kiger and Varpio27 Coding was performed using Atlas.ti Version 23.1.1, 28 and themes were organized in Microsoft Word.
Ethical considerations
Ethical approval was obtained from NUST and MoHSS. Informed consent was obtained from all participants. The online questionnaire contained an information sheet and a tick-box for digital consent (Supplemental File 1), while FDG participants provided written informed consent (Supplemental File 2). Data was anonymised and stored securely on a password-protected device, with access limited to the researchers.
Results
Quantitative phase
Respondent characteristics
Of the 102 responses, 62.7% (n = 64) were female, 63.7% (n = 65) were between 30 and 39 years, 62.7% (n = 64) worked in hospitals, and 42.2% (n = 43) had 6–10 years’ work experience (Table 1). A certificate (National Qualifications Framework [NQF] level 5) was the highest qualification for 29 (28.4%) respondents, while 26 (25.5%) had an honors, professional degree, or postgraduate diploma (NQF level 8). Most respondents were nurses (n = 44, 43.1%), with a similar distribution of responses observed per district. Only 32 (31.4%) have been vaccinated against TB, while 12 (11.8%) have been previously infected with TB. Less than half (n = 46, 45.1%) of respondents received TB IPC training in the last 2 years.
Respondent characteristics
Note. HIV, human immunodeficiency virus; IPC, infection prevention and control; MDR, multidrug resistance; NQF, National Qualifications Framework; TB, tuberculosis.
TB IPC knowledge, attitudes, and practices
The mean knowledge score was 7.4 (SD .77, 95% CI 7.23–7.55) of 10 (74.0%) with 93 (91.2%) respondents obtaining ≥ 60%, suggesting good TB IPC knowledge. The mean score for attitude was 8.3 (SD 1.24, 95%CI 8.07–8.60) of 10 (83.0%), while 87 respondents (85.3%) demonstrated positive attitudes (≥ 60%). For TB IPC practices, the mean score was 14.9 (SD 2.5, 95% CI 14.2–15.5) of 20 (74.5%). Approximately two-thirds of respondents (n = 63, 61.8%) demonstrated good TB IPC practices (≥ 60%) (according to the scope of practice). Supplemental File 3 illustrates responses to the TB IPC KAP statements. Cronbach’s alpha for the knowledge, attitudes, and practice sections was .57, .17, and .87, respectively.
Characteristics associated with TB IPC knowledge
The Pearson χ2 test for Independence was conducted to identify associations between respondent characteristics and knowledge (good or poor). A significant association was found with district (P = .001), education level (P = .010), and department (P = .036). Respondents from the Karasburg (n = 32, 36.5%) and Lüderitz (n = 30, 35.2%) districts appeared more knowledgeable than those from Keetmanshoop (n = 24, 28.3%), while respondents with NQF 5 and 8 qualifications were likewise more knowledgeable than others. Moreover, respondents from the MDR-TB ward (n = 20, 23.2%) and those in “other” departments (n = 33, 38.1%) were more knowledgeable than those working in the general ward, casualty, HIV care, laboratory, outpatient, and radiology departments.
Barriers and facilitators to TB IPC adherence
Respondents reported 18 barriers and 13 facilitators to TB IPC adherence. Staff deficit was the main barrier (n = 47, 29.2%), and training (n = 20, 22.5%) was the main facilitator reported (Table 2).
Barriers and facilitators to TB IPC adherence
Note. HCW, healthcare worker; IPC, infection prevention and control; PPE, personal protective equipment; TB, tuberculosis.
Qualitative phase
Participant characteristics
Eighteen participants participated in the 3 FGDs. Most participants were nurses (n = 4, 22.2%) in supervisory positions, environmental health practitioners (n = 5, 27.8%), DTLCs (n = 2, 11.1%), and PHC supervisors (n = 2, 11.1%). Ten (55.6%) participants were female, while 44.4% (n = 8) were between 30 and 39 years, and two-thirds practiced for >5 years (n = 12, 66.7%) (Table 3).
Characteristics of participants (n = 18)
Note. ART, anti-retroviral treatment; DFS, district field supervisor; DS, disease surveillance; DTLC, District TB and Leprosy Coordinator; EHP, environmental health practitioner; PHC, primary health care; TB, tuberculosis.
Four themes emerged from the data:
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1. Namibia’s effort to fight TB.
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2. Healthcare challenges: Exploring TB IPC implementation and adherence barriers.
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3. Catalyst for change: Facilitators in the implementation and adherence to TB IPC measures.
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4. Improving TB IPC for a healthier tomorrow.
Theme 1: Namibia’s effort to fight TB (Table 4)
Participants described a strong commitment to fighting TB through clear IPC measures involving isolation (Q1), triaging and masking patients (Q2), using administrative strategies like FAST (Finding TB cases Actively, Separating safely, Treating effectively) and contact tracing (Q3), ensuring laboratory safety with biosafety cabinets (Q4), and consistent use of PPE (Q5).
Quotations supporting Themes 1 and 2
Theme 2: Healthcare challenges: exploring TB IPC implementation and adherence barriers (Table 4)
Participants highlighted barriers such as poor infrastructure (Q6), lack of transport and resources (Q7), persistent stigma in communities (Q8), staff shortages affecting workload and policy implementation (Q9), and patient non-adherence to treatment as well as non-compliance by some HCWs (Q10).
Theme 3: Catalyst for change: facilitators in the implementation and adherence to TB IPC measures (Table 5)
Facilitators included effective communication when TB cases are identified (Q11), community and patient health education (Q12), adherence to good TB IPC practices such as consistent mask use and quarterly screening (Q13), sufficient availability of PPE (Q14), and HCW training and education on TB IPC policies (Q15).
Quotations supporting Themes 3 and 4
Theme 4: Improving TB IPC for a healthier tomorrow (Table 5)
Participants suggested strategies for improvement, including upgrading infrastructure for improved ventilation and space (Q16), hiring and retaining sufficient staff (Q17), strengthening training and health education (Q18), addressing stigma and misinformation (Q19), and monitoring PPE usage to ensure compliance (Q20).
Discussion
The study findings revealed high levels of TB IPC knowledge (91.2%) and attitudes (85.3%), but less optimal practices (61.8%), suggesting a disconnect between TB IPC knowledge and practices of HCWs in the region. Staff deficit and training were the most reported barriers and facilitators, respectively. Conversely, the FGDs revealed that while TB IPC policies existed, their implementation was inconsistent, due to contextual barriers including limited infrastructure, staff shortages, stigma, and inconsistent training. Facilitators included effective communication, health education, and PPE availability.
The TB IPC knowledge observed in this study aligns with findings from Nigeria Reference Ajayi and Isiyaku25 but contrasts with studies from Uganda and Namibia reporting poorer knowledge levels. Reference Buregyeya, Kasasa and Mitchell8,Reference Shaanika9 Disparities may be attributed to differences in knowledge scoring cut-offs and respondent profiles across studies. Consistent with another study, Reference Shaanika9 respondents with certificate-level (NQF 5) and honors/professional degree/postgraduate diploma (NQF 8) qualifications demonstrated higher knowledge scores. This may have been attributed to specifically tailored training in TB IPC and hands-on experience through training or work experiences, reinforcing their knowledge. District-level variances also emerged, with Karasburg respondents showing higher knowledge levels, which again might be linked to level of education.
The study revealed predominantly positive attitudes toward TB IPC, echoing other studies. Reference Buregyeya, Kasasa and Mitchell8,Reference Bhebhe, Van Rooyen and Steinberg29 In contrast, negative attitudes have been shown not to foster TB IPC behavior, hindering administrative and environmental TB IPC compliance. Reference Tshitangano30
The implementation of TB IPC measures in public health facilities in //Karas region showed variation. Compared to environmental and PPE control measures, most administrative control measures were poorly implemented. Nevertheless, the current study revealed good overall TB IPC practices. Moreover, the gap between the KAP may be attributable to structural barriers faced in public health settings, such as high workloads, possibly leading to the deprioritization of key administrative controls such as patient education, screening, and triaging. Similarly, poor TB IPC implementation has been documented in Mozambique and South Africa. Reference Noé, Ribeiro and Anselmo31,Reference Sissolak, Marais and Mehtar32
Despite the existence of TB IPC policies, some HCWs were uninformed about or lacked access to the guidelines. These findings align with previous research indicating poorly disseminated TB IPC guidelines in health facilities. Reference Gyem, Ahmad and Mahendradhata33 Moreover, the fragmentation of TB IPC content limited to specific programs hampers comprehensive adherence. Reference Islam34 This highlights the importance of having consistent, clearly structured, and widely disseminated guidelines that all HCWs can access and apply.
The qualitative findings also support the global TB IPC framework, which emphasizes the hierarchy of administrative, environmental, and personal protective measures. 5 However, administrative measures remained the weakest identified component in this study.
Several barriers impeded the effective implementation of TB IPC measures, including critical human resource shortages, high patient workload, and inadequate infrastructure, factors that have similarly been reported in other high TB-burden settings. Reference Narasimhan, Wood, Macintyre and Mathai35 Poor coordination between stakeholders, especially at district levels, and inconsistent availability of TB IPC guidelines further undermine standardized implementation. Reference Tan, Kallon, Colvin and Grant12
Despite these challenges, key facilitators supported TB IPC efforts. These included routine training, the appointment of dedicated focal persons, and the existence of national TB IPC policies, which were widely implemented across facilities. The presence of multidisciplinary TB IPC committees and supportive supervision further contributed to strengthening facility-level implementation, even in resource-constrained environments. Reference Curless, Gerland and Maragakis36
The study was limited to the //Karas region, restricting generalizability. Adding additional regions in future research would add further insight. Participant reluctance may have also influenced responses despite being assured of anonymity and confidentiality. Moreover, the questionnaire received a low response rate, likely due to staff shortages, poor internet connectivity in remote areas, and possible survey fatigue, which may introduce non-response bias and limit representativeness. Consequently, the findings may not fully represent all HCWs in the region, and key measures such as TB IPC knowledge or adherence may be over- or underestimated. To improve participation, the questionnaire link was shared via social media along with periodic reminders. Furthermore, the absence of established IPC committees in most districts may have limited the depth and accuracy of FGD responses. Additionally, the internal consistency of the knowledge and attitude scales was low, suggesting caution when interpreting these results. Despite these limitations, the findings remain applicable to TB focal persons working in public health facilities within the region.
In conclusion, this study provides valuable insight into the KAP of HCWs regarding TB IPC in the //Karas region of Namibia, revealing important gaps in implementation despite widespread policy uptake. Our findings underscore the significance of strengthening HCW capacity through ongoing training, ensuring accessibility of TB IPC guidelines, and fostering interdisciplinary collaboration for effective policy implementation. Priority improvements should focus on improving ventilation and increasing isolation room capacity, as poor infrastructure was a major barrier to effective TB IPC. Other critical barriers to address include staff shortages, inconsistent TB IPC training, limited PPE, and persistent stigma, all of which impede TB IPC adherence. By highlighting these factors, the study contributes to the development of evidence-based TB IPC strategies that can improve IPC in health settings.
Future research should focus on conducting longitudinal studies to track the implementation of TB IPC measures and adherence among HCWs. This could assist in identifying trends, challenges, and variations in behavior over time, allowing for the evaluation of the sustainability of TB IPC practices and the effectiveness of ongoing interventions.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/ash.2025.10248
Acknowledgments
The authors sincerely thank all the HCWs and the DCC for participating in the study. Special recognition goes to their statisticians for their valuable contributions. They also used OpenAI’s ChatGPT to assist with language refinement and improve the clarity of the manuscript. All content was reviewed and approved by the authors.
Financial support
No financial assistance was provided relevant to this article.
Competing interests
All authors report no conflicts of interest relevant to this article.
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